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Corticosteroid injection is a common treatment for individuals experiencing musculoskeletal pain, and it is part of the management of numerous orthopaedic conditions. However, there is concern about offering corticosteroid injections for musculoskeletal pain because of the possibility of secondary adrenal insufficiency.In this systematic review and meta-analysis of prospective studies, we asked: (1) Are corticosteroid injections associated with secondary adrenal insufficiency as measured by 7-day morning serum cortisol? (2) Does this association differ depending on whether the shot was administered in the spine or the appendicular skeleton?We searched the Allied and Complementary Medicine (AMED), Embase, EmCare, MEDLINE, CINAHL, and Web of Science from inception to January 22, 2021. We retrieved 4303 unique records, of which 17 were eventually included. Study appraisal was via the Downs and Black tool, with an average quality rating of fair. A Grading of Recommendations, Assessment, Development, and Evaluations assessment was conducted with the overall certainty of evidence being low to moderate. Reflecting heterogeneity in the study estimates, a pooled random-effects estimate of cortisol levels 7 days after corticosteroid injection was calculated. Fifteen studies or subgroups (254 participants) provided appropriate estimates for statistical pooling. A total of 106 participants received a spine injection, and 148 participants received an appendicular skeleton injection, including the glenohumeral joint, subacromial bursa, trochanteric bursa, and knee.Seven days after corticosteroid injection, the mean morning serum cortisol was 212 nmol/L (95% confidence interval 133 to 290), suggesting that secondary adrenal insufficiency was a possible outcome. There is a difference in the secondary adrenal insufficiency risk depending on whether the injection was in the spine or the appendicular skeleton. For spinal injection, the mean cortisol was 98 nmol/L (95% CI 48 to 149), suggesting secondary adrenal insufficiency was likely. For appendicular skeleton injection the mean cortisol was 311 nmol/L (95% CI 213 to 409) suggesting hypothalamic-pituitary-adrenal axis integrity was likely.Clinicians offering spinal injections should discuss the possibility of short-term secondary adrenal insufficiency with patients, and together, they can decide whether the treatment remains appropriate and whether mitigation strategies are needed. Clinicians offering appendicular skeleton injections should not limit care because of concerns about secondary adrenal insufficiency based on the best available evidence, and clinical guidelines could be reviewed accordingly. Further research is needed to understand whether age and/or sex determine risk of secondary adrenal insufficiency and what clinical impact secondary adrenal insufficiency has on patients undergoing spinal injection.Level IV, therapeutic study.

Objective To investigate the effectiveness of early versus delayed rehabilitation following total shoulder replacement. Design Intervention systematic review with narrative synthesis. Literature search MEDLINE, EMBASE, CINAHL, Scopus and the Cochrane Library were searched from inception to the 29th of July 2021. Study selection criteria Randomised controlled trials comparing early versus delayed rehabilitation following primary anatomic, primary reverse, or revision total shoulder replacement. Data synthesis A revised Cochrane risk of bias assessment tool for randomised controlled trials was used, as well as the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence. A narrative synthesis was undertaken. Results Three eligible randomised controlled trials ( n = 230) were included. There was very low-quality evidence of no statistically significant difference ( P > 0.05) in pain, shoulder function, health-related quality of life or lesser tuberosity osteotomy healing at 12 months between early or delayed rehabilitation. There was conflicting and very low-quality evidence of a difference between the effect of early and delayed rehabilitation on shoulder range of movement. There was limited, very low-quality evidence of statistically significantly improved pain and function ( P Conclusions No differences were seen in patient-reported or clinician-reported outcomes at 12 months post-surgery between early and delayed rehabilitation following total shoulder replacement. There is very low-quality evidence that early rehabilitation may improve shoulder pain and function in the early post-operative phase following anatomic total shoulder replacement.

Objective: To evaluate the feasibility of a multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of early patient-directed rehabilitation versus standard rehabilitation following surgical repair of the rotator cuff of the shoulder. Design: Two-arm, multi-centre pilot and feasibility randomised controlled trial. Setting: Five National Health Service hospitals in England. Participants: Adults ( n = 73) with non-traumatic rotator cuff tears scheduled for repair were recruited and randomly allocated remotely prior to surgery. Interventions: Early patient-directed rehabilitation ( n = 37); advised to remove their sling as soon as able and move as symptoms allow. Standard rehabilitation ( n = 36); sling immobilisation for four weeks. Measures: (1) Randomisation of 20% or more eligible patients. (2) Difference in time out of sling of 40% or more between groups. (3) Follow-up greater than 70%. Results: 73/185 (39%) potentially eligible patients were randomised. Twenty participants were withdrawn, 11 due to not receiving rotator cuff repair. The between-group difference in proportions of participants who exceeded the cut-off of 222.6 hours out of the sling was 50% (80% CI = 29%, 72%), with the early patient-directed rehabilitation group reporting greater time out of sling. 52/73 (71%) and 52/53 (98%) participants were followed-up at 12 weeks when withdrawals were included and excluded respectively. Eighteen full-thickness re-tears were reported (early patient-directed rehabilitation = 7, standard rehabilitation = 11). Five serious adverse events were reported. Conclusion: A main randomised controlled trial is feasible but would require allocation of participants following surgery to counter the issue of withdrawal due to not receiving surgery.

Introduction Approaches to rehabilitation following rotator cuff repair are variable but typically include 4-6 weeks of immobilisation followed by a gradual introduction of movement and activity. However, research has questioned whether such an approach is optimal. The aim of this study was to undertake an updated survey to understand whether practice has evolved in line with contemporary research. Methods An electronic survey was developed describing three case scenarios (medium-sized rotator cuff repair [2 cm], large-sized rotator cuff repair [4 cm] and large-sized rotator cuff repair with biceps tenodesis). Clinicians involved with rehabilitation following rotator cuff repair were invited to participate. Results 129 responses were received (United Kingdom = 87, other regions [ORs] = 42). Respondents would most commonly recommend four to six weeks of immobilisation for all case scenarios. Passive movement would commence during this period, with active movement recommended from four to six weeks. Resisted exercise would commence between seven to 12 weeks along with return to driving. There were some minor differences in recommendations between respondents from the United Kingdom and ORs, including a greater proportion from the United Kingdom recommending sling immobilisation rather than abduction brace immobilisation. Conclusion For many respondents to this survey, rehabilitation for the three case scenarios was similar and has not evolved in line with contemporary research evidence. The reasons behind this need to be explored and incorporated into the design of future research evaluating rehabilitation following rotator cuff repair.

Introduction The prevalence of shoulder arthroplasty (SA) is rising, but there is limited research evaluating rehabilitation following SA and whether there is an optimal approach remains unknown. The aim of this study was to understand current National Health Service (NHS) practice for rehabilitation following SA as a platform for conducting much needed further research. Methods Two reviewers independently undertook electronic searches for publicly available information sheets (PIS) from websites of NHS Trusts that included detail about rehabilitation following SA, for example, duration of immobilisation. One reviewer extracted data, and a second reviewer verified this. Ethical approval Not required. Results Forty-three PIS from 40 Trusts were identified. Twenty-four referred to more than one type of arthroplasty (anatomic, reverse and hemiarthroplasty) but did not describe different approaches to rehabilitation based on prosthesis type. Twenty-five PIS provided some instruction regarding movement restrictions, which varied considerably. All PIS referred to postoperative immobilisation, typically with a sling, with median duration of 4 weeks (range 0 to 8). Thirty-four PIS reported commencing passive exercise immediately. Median time to commencing active exercise was 4 weeks (range 1 to 6) and 5 weeks (range 1 to 16) for resisted exercise. Median time expected to return to driving was 6 weeks (range 3 to 12) and general work 12 weeks (range 3 to 26). Conclusion This study has highlighted significant heterogeneity between rehabilitation approaches following SA, not previously reported in the United Kingdom, with a lack of specific rehabilitation PIS for different prosthesis types. Our results will facilitate evaluation of rehabilitation strategies in future research.

Background Primary shoulder arthroplasty can significantly improve quality of life; however, the glenoid baseplate remains the most common component to loosen, which may result in implant failure and subsequent revision surgery. Radiostereometric analysis (RSA) is considered the gold standard for accurate measurement of micro-motion between implant and bone. The aims of this study were to compare migration of the Lima SMR porous titanium hydroxyapatite (HA) coated and non-hydroxyapatite (non-HA) coated glenoid components through a prospective, randomized 2-arm trial using RSA, whilst also comparing clinical and functional outcomes. Methods Twenty patients were randomized into 2 equal (HA and non-HA coated) groups with all patients undergoing primary anatomic shoulder arthroplasty, at which time tantalum beads were also inserted. RSA imaging was performed immediately postoperatively, then at 3, 6, 12, and 24 months postprocedure. These images were digitized and analyzed using model-based RSA software. All patients completed Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES) score, Constant Score (CS) and Visual Analogue Scale (VAS) pain scores pre-and postoperatively at the aforementioned time points. Unpaired t-tests were used for clinical outcome data; Mann-Whitney U tests were used for RSA data. Significance levels were set at P Results Mean age for the HA group was 72.3 years; 69.5 years for the non-HA group. Mean follow-up for both groups was above 36 months. No significant differences in glenoid migration were observed at each of the postoperative time points; the only exception being at 12 months (non-HA group displaying significantly greater rotation in the z-axis). The HA group displayed fractionally more translation in the x- and z-axes at all time points (not significant). Rotation in the z-axis was marginally greater at all postoperative time points in the non-HA group. Median total migration values revealed greater motion for the non-HA group at 3, 6, and 12 months (not significant). All clinical outcome measures improved significantly within each group; no statistical differences were observed between the groups for any outcome measure. One patient in each group underwent revision surgery to reverse shoulder arthroplasty due to unexplained pain (HA group) and cuff failure (non-HA group) only. Radiolucent lines were noted in 2 patients who are still under follow-up. Conclusion This study has revealed promising early results of both HA coated and non-HA coated implants, however, hydroxyapatite coating of glenoid components does not significantly improve outcome scores nor provide extra stability compared to non-hydroxyapatite coated implants at 2 years postprocedure. Level of evidence Level II; Randomized Controlled Trial

Objective To investigate the effectiveness of early rehabilitation compared with delayed/standard rehabilitation after rotator cuff repair for pain, function, range of movement, strength, and repair integrity. Design Systematic review and meta-analyses. Methods We searched databases and included randomised controlled trials (RCTs) comparing early with delayed/standard rehabilitation for patients undergoing rotator cuff repair surgery. We assessed risk of bias of the RCTs using the Cochrane RoB 2 tool. Results Twenty RCTs, with 1841 patients, were included. The majority of the RCTs were of high or unclear risk of overall bias. We found substantial variations in the rehabilitation programmes, time in the sling and timing of exercise progression. We found no statistically significant differences for pain and function at any follow-up except for the outcome measure Single Assessment Numeric Evaluation at six months (MD: 6.54; 95%CI: 2.24–10.84) in favour of early rehabilitation. We found statistically significant differences in favour of early rehabilitation for shoulder flexion at six weeks (MD: 7.36; 95%CI: 2.66–12.06), three (MD: 8.45; 95%CI: 3.43–13.47) and six months (MD: 3.57; 95%CI: 0.81–6.32) and one year (MD: 1.42; 95%CI: 0.21–2.64) and similar differences for other planes of movement. In terms of repair integrity, early mobilisation does not seem to increase the risk of re-tears (OR:1.05; 95%CI: 0.64–1.75). Discussion Current approaches to early mobilisation, based largely on early introduction of passive movement, did not demonstrate significant differences in most clinical outcomes, although we found statistically significant differences in favour of early rehabilitation for range of movement. Importantly, there were no differences in repair integrity between early and delayed/standard rehabilitation. Most rehabilitation programmes did not consider early active movement as soon as the patient feels able. With ongoing variation in rehabilitation protocols there remains a need for large high quality RCT to inform the optimal approach to rehabilitation after rotator cuff repair surgery.

Pregnancy-related lumbopelvic pain is a term used to describe pain emanating from the lumbar spine or pelvic girdle that develops either during pregnancy or in the immediate post-partum period. Although it is estimated that up to 70% of pregnant women will report lumbopelvic pain at some point during their pregnancy, there is a paucity of literature pertaining to the prevention of the condition. This study was therefore undertaken in order to explore the feasibility of a larger-scale study into the prevention of pregnancy-related lumbopelvic pain using a single exercise and advice-based physiotherapy intervention in early pregnancy. Several aspects of feasibility were addressed and it was highlighted that several modifications would have to be made to the protocol in order to ensure successful completion of a larger-scale study. The tendency towards improved outcomes in the study group was however an encouraging finding and supports the need for further research in this field.

The 6-hydroxynona-2,7-dienylstananne 10 reacts with aldehydes after transmetallation with tin(IV) bromide with syn -selective 1,7-induction (1,7- syn : 1,7- anti = ca . 90 : 10). Ireland-Claisen rearrangements of the acetates 28a,b prepared from the syn -benzaldehyde product 14 , gave methyl (3 R ,11 R )-3-methyl-11-(arylmethoxy)-11-phenylundeca-4,8-dienoates 30a,b stereoselectively.

The 6-hydroxynona-2,7-dienylstananne 10 reacts with aldehydes after transmetallation with tin(IV) bromide with syn -selective 1,7-induction (1,7- syn : 1,7- anti = ca . 90 : 10). Ireland-Claisen rearrangements of the acetates 28a,b prepared from the syn -benzaldehyde product 14 , gave methyl (3 R ,11 R )-3-methyl-11-(arylmethoxy)-11-phenylundeca-4,8-dienoates 30a,b stereoselectively.